Severe head injury combined with hyperglycemia clinical analysis of 256 cases
【Abstract】 Objective To investigate the severe head injury patients with combined hyperlipidemia characterized by high glucose and treatment with a view to raising the level of treatment for such patients. Method from January 2001 to December 2007 admitted to our hospital with severe head injury combined 256 cases of hyperglycemia, through its formation mechanism, treatment, and more sum up the situation after the analysis.
Results Glasgow outcome scale (GOS) ? grade 35 cases of death, ? grade
plant survival in 17 cases, ? grade 44 cases of severe disability, ?
grade residual 68 cases, ? level good in 92 cases of high blood sugar, died, and disability high. Conclusion Patients with severe traumatic brain injury and brain injury itself, elevated blood glucose pathological mechanisms related to rational use of insulin is safe and effective treatment of high blood sugar, and can quickly control high blood sugar, can improve neurological function in patients with traumatic brain injury and prognosis, increase the survival rate .
Key words severe head injury characterized by hyperglycemia insulin therapy
From January 2001 to December 2007, the Court were treated severe head
injury patients with 256 cases of hyperglycemia were analyzed injury characteristics, treatment and prognosis are summarized below.
A clinical data
1.1 General information on 256 cases of patients in this group of 192 cases of male and female 64 cases; aged 5 to 74 years old, with an average 46 years old, are in line with severe head injury criteria, including Glasgow coma scale (GCS) score 3 to 4 minutes and 41 cases, 5 ~ 6 minutes and 57 cases, 7 to 8 pm 158 cases. There was no major organ pre-hospital
acute and chronic disease, no history of diabetes, history of pre-injury
alcohol-free, and no history of multiple injuries. All the patients were not within 24h before blood transfusion and the use of high-dose hormones,
which excluded patients with diabetes, was obtained within 24h after injury, the elbow vein 1.5 ~ 2.0ml, using glucose oxidase determination of serum glucose, blood glucose> 7.0mmol / L 82 cases (67.4%), blood glucose> 11.1mmol / L 44 cases (32.6%), glycosylated hemoglobin were "7.7%.
1.2 injuries cause 150 cases of traffic accident injury, combat injury in 52 cases, 41 cases of falls, the other 13 cases.
1.3 image data when patients were admitted to hospital with routine cranial helical CT examination, 134 patients with cerebral contusion and
laceration, 12 cases of primary brain stem injury, diffuse axonal injury in 32 cases, 68 cases of intracranial hematoma (epidural hematoma 30 cases, subdural or intracerebral hematoma, 15 cases of multiple intracranial hematomas in 23 cases), intraventricular hemorrhage in 10 cases.
1.4 Conventional treatment methods for bleeding, dehydration, hormones, nutrition, nerve, hyperbaric oxygen, prevent infection and complications comprehensive treatment, but also the use of small doses of
insulin therapy, blood glucose> 11.1mmol / L glucose infusion period, the use of micro-pump sustained, slow pump insulin, the dose varies, generally 0.1 ~ 0.2U / (kg * h), check blood sugar every 2h, so that blood sugar down to 6.11mmol / L can be about. If blood glucose <11.1mmol / L, then switch to subcutaneous insulin 4 ~ 8U, 1 time / 4h, may temporarily increase use. If the blood sugar has returned to normal, you can disable the insulin. Mining production in peripheral blood by the United States
Johnson & Johnson Rapid Determination of blood glucose meters blood glucose, blood glucose test blood sugar to normal after the adoption. 2 weeks after the blood glucose levels returned to normal in 16 cases, more than 5 ~ 14d blood sugar were normal.
Glasgow outcome scale (GOS): ? grade 37 cases of death, ? grade
plant survival in 17 cases, ? grade 42 cases of severe disability, ?
grade residual 68 cases, ? 92 patients with a good grade. The higher
blood sugar, died of illness and disability the higher the result of
different blood glucose groups in Table 1. Table 1 Comparison of different blood glucose GOS Note: * P <0.01, # P <0.05 reposted elsewhere in the paper for free download http://
3.1 severe head injury with the formation mechanism of high blood
sugar, severe traumatic brain injury occurs after the body's stress response, intracranial pressure is increased, affecting the pituitary -
adrenal axis function, central and peripheral sympathetic nervous system stimulant, causing neurological and endocrine structure and function of changes to the blood circulation in catecholamine, glucagon, corticosteroids, and growth hormone, pituitary hormones, thyroid hormone and other catabolic hormone secretion due to increased glucose utilization
barriers, lack of insulin secretion, endogenous glucogenic significantly increase, these catabolic hormones in addition to direct stimulation of glycogen breakdown, protein, fat decomposed (alanine, glycerol) and increased gluconeogenesis, but also through various means antagonistic biological effects of insulin , post-traumatic to The number of cells
of the insulin receptor and insulin receptor in a significant reduction in the rate of maximum specific binding of reduced insulin sensitivity was
reduced, so that glucose can not be effectively removed from the cycle, and further stimulate insulin release, leading to hyperinsulinemia caused by insulin resistance. The foregoing factors, and high blood sugar is a manifestation of the stress response is a complex hormonal imbalance
caused by the body to make insulin and glucagon balance between the destruction, leading to high blood sugar .
3.2 In some cases, characterized by elevated blood sugar is beneficial, because the stress state, are deficient in calories, in the
absence of such reactions can lead to low blood sugar, but severe high blood sugar experience is a negative impact on the machine: (1) lactic acidosis: the early stage after severe brain injury in regional cerebral blood flow reduction occurred, leading to cerebral ischemia, hypoxia, high blood sugar can aggravate ischemic brain damage during hypoxia, which makes anaerobic glycolysis active, cerebral Organization of lactic acid accumulation, causing a wider range of brain tissue intracellular
acidosis, secondary series of reactions, including the accumulation of intracellular calcium, cell type a large number of toxic fatty acids and glutamate release in brain tissue reduced ability to use glucose, ATP synthesis impairment, resulting in nerve cell energy metabolism,
eventually leading to secondary injury of brain cells. Acidosis increased endothelial cell edema and glial cell damage, can cause damage to blood-
brain barrier and increased brain damage and cerebral edema; (2),
hyperosmolar syndrome: a long and significant increase in hyperglycemia can lead to high bleeding disease, which can cause cell dehydration and affect cell metabolism and physiological functions, especially the brain cell function; if hyperosmolar state occurs too fast, too strong level,
then easily lead to severe dehydration shrinkage of brain cells, attachment of the small blood vessels subject to mechanical stress caused by meningeal tear hematoma, brain hemorrhage and other real point of intracranial hemorrhage; osmotic pressure rise, high blood sugar caused by increased blood viscosity, caused by diffuse small vessel disease, or even completely blocked lumen affect the collateral circulation , leading to brain tissue hypoxia, secondary cerebral thrombosis, cerebral infarction
occurs ; (3) infection: high blood sugar often damages the body's immune system, lymphocytes decreased neutrophils is not easy to attach to vascular endothelium, leukocyte chemotaxis based, adhesion and phagocytosis decreased bactericidal activity of damaged, increasing the chances of infection; (4) Prognosis: High blood sugar can exacerbate neurological dysfunction, affecting the nervous system prognosis, the more
severe brain injury, the higher the blood glucose level, the prognosis is
more poor, the degree of brain injury after injury, a positive correlation between blood glucose levels and effective control of blood glucose can improve the prognosis of patients.
3.3 The treatment of high blood sugar can increase the rate of
deformity in patients with brain injury, mortality, blood glucose maintained at the normal range, can reduce mortality. In the effective treatment as soon as possible on the basis of the original disease to take active measures to adjust glucose metabolism, control blood sugar utmost
important to note: (1) using micro-pump method, easy to adjust the input
speed and in a timely withdrawal of insulin drug; (2) In the course of treatment need to test blood sugar closely, to observe the performance of low blood sugar, if necessary, detect 1 / 1 ~ 2h. The treatment of high blood sugar must guard against the importation of too much too fast and too much insulin hypotonic solution, pay attention to blood sugar dropped too quickly may increase brain edema, can cause brain edema and
intracranial hypertension, it sought to steady blood sugar drop, the speed control in an hour 4.4 ~ 6.64mmol / L, insulin-application process in this
group is not found in the phenomenon of low blood sugar; (3) of the patients with high blood sugar, taking insulin resistance, then increase the dose of insulin effects are poor, through the aggressive treatment of primary disease full rehydration, low-dose continuous intravenous insulin
pump, can make blood sugar drop. The group of 15 patients, according to
the treatment, blood glucose control and stability both; (4) The critical state of high blood sugar are mostly a transient, early after injury as possible to avoid or minimize use of glucose liquid, can be balanced salt, Ringer's solution, etc. seepage glucose solution, etc., on the positive handling of the original disease, limit sugar and after application of small doses of insulin, high blood sugar gradually eased, then a corresponding reduction in insulin dosage, when blood glucose fell to
<6.11mmol / L, when out of insulin, while continuing to monitor blood glucose , according to blood glucose changes in deciding whether to re-use
of insulin ; (5) Note that water and electrolyte disorders, acid-base
imbalance. Note that during the infusion the incidence of diabetic
hyperosmolar coma, pay attention to control the importation of sugar and sodium, there hyperosmolar coma Diabetic patients with increased disturbance of consciousness, easily mistaken for increased cerebral edema or brain hematoma formation. And should therefore be in the event of disturbance of consciousness is not improved or exacerbated when the early detection of blood biochemical indices and blood sugar, if necessary, line of head CT, MRI examination. To exclude intracranial hematoma, early
detection of diabetic hyperosmolar coma, this group of patients with high glucose does not appear hyperosmolality; (6) The goal of blood glucose control, blood glucose control in 6.11mmol / L or so, related study found that the same blood glucose "11.1 mmol / L group compared blood glucose control <6.11mmol / L group significantly improved the prognosis ; (7) in patients with severe traumatic brain injury admitted to hospital or within 1 day after the first blood glucose> 11.1mmol / L, indicates a poor
prognosis  for blood glucose> 11.1mmol / L to I-insulin micro pump. (8)
The higher the blood glucose and insulin using the longer the worse the prognosis , which have a certain effect on prognosis. This group of
studies have shown that rational use of insulin is safe and effective treatment of high blood sugar, and can quickly control high blood sugar, to avoid adding to brain damage, the condition of stability changes in traumatic brain injury and lower the fatality rate is essential.
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